Take Our Dry Eye Quiz

Are you experiencing dry, itchy and/or irritated eyes? Take our dry eye quiz to help determine if you may have a type of Dry Eye Syndrome.

Dry Eye Quiz: SPEED II Questionnaire

Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.

First Name *

Last Name *

Date: *

Date of Birth (MM/DD/YY): *

Sex: *

M

F

Email: *

Address:

Phone: *

Comments

Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below:

0 - Never, 1 - Sometimes, 2 - Often, 3 - Constant

Dryness, Grittiness or Scratchiness *

0

1

2

3

Soreness or Irritation *

0

1

2

3

Burning or Watering *

0

1

2

3

Eye Fatigue *

0

1

2

3

Report the SEVERITY of your symptoms using the ratings list below:

0 - No problems

1 - Tolerable – not perfect but not uncomfortable

2 - Uncomfortable – irritating but does not interfere with my day

3 - Bothersome – irritating and interferes with my day

4 - Intolerable – unable to perform my daily tasks

Dryness, Grittiness or Scratchiness *

0

1

2

3

4

Soreness or Irritation *

0

1

2

3

4

Burning or Watering *

0

1

2

3

4

Eye Fatigue *

0

1

2

3

4

Please check if you have experienced symptoms:

Today

Within the last 72 hours

Within past 3 months

Do you use eye drops and/or ointment? *

Yes

No

If yes, which drops do you use?

If yes, how often?

Have you been told that you have blepharitis? *

Yes

No

Have you been treated for a stye? *

Yes

No

Do you have fluctuating vision problems? (That can be corrected with blinking) *

Yes

No

If yes, how often?

Never

Sometimes

Frequently

A lot/Always

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